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Quality Care Health Plan (QCHP) Changes

As a result of discussions between the Department of Central Management Services, the Department of Healthcare and Family Services and the various bargaining unit entities which represent State employees covered under the Group Insurance Program, changes to the Quality Care Health Plan (QCHP) are being implemented effective March 1, 2011.

The 25-mile rule, which allowed members who live more than 25 miles from an in-network facility to have charges paid at a higher rate if services were rendered at an out-of-network facility or by an out-of-network provider, will no longer apply.

All services received from out-of-network providers, including physician, hospital and ancillary services, will be applied only to the out-of-network, $4400.00 individual/$8800.00 family out-of-pocket maximum. Previously only out-of-network hospital services applied to this maximum.

All services received from in-network providers, including physician, hospital and ancillary services, will be applied only to the in-network, $1200.00 individual/$3000.00 family out-of-pocket maximum. Previously, all charges except charges for out-of-network hospital services applied to this maximum.

Charges for all out-of-network services, including physician, hospital and ancillary services, will be covered at 70% of the usual and customary (U&C) after the plan year deductible. In other words, the Plan will pay 70% of allowable expenses and you, the member, will be responsible for the other 30% co-insurance plus any amounts over the U&C.

These changes are the result of discussions and agreement between the Department of Central Management Services, the Department of Healthcare and Family Services and the various bargaining unit entities which represent State employees covered under the Group Insurance Program.

Charges for all in-network services, including physician, hospital and ancillary services (other than those specifically delineated by law or collective bargaining agreement at 100%), continue to be covered at 90%. In other words, the Plan pays 90% of allowable expenses and you, the member, are responsible for the remaining 10% co-insurance after the plan year deductible has been met. Remember: Plan participants receive enhanced benefits resulting in lower out of pocket costs when receiving services from a QCHP network provider.

Plan participants with questions regarding these changes should contact the Bureau of Benefits, Member Services Unit at (800) 442-1300.